State of Maryland

A Health Records Technician Trainee is the entry level of work compiling and maintaining health records in a State facility or local health department.  Employees in this classification do not supervise other positions.

Employees in this classification receive close supervision from a Health Records Technician Supervisor or Health Records Program Supervisor.

Positions in this classification are evaluated by using the classification job evaluation methodology.  The use of this method involves comparing the assigned duties and responsibilities of a position to the job criteria found in the Nature of Work and Examples of Work sections of the class specification.

The Health Records Technician Trainee, Health Records Technician I, and Health Records Technician II are differentiated on the basis of the degree of supervisory control exercised by the supervisor over these employees.  The Health Records Technician Trainee learns to perform duties under close supervision.  The Health Records Technician I performs duties under close supervision at times and under general supervision at other times depending on the complexity of the specific duty being performed.  The Health Records Technician II performs the full range of duties and responsibilities under general supervision.

Learns to use and maintain a state facility’s system of medical files and records relating to patients' diagnoses, treatments, admissions, discharges and daily patient census changes;

Learns to assemble, classify and index medical data in accordance with established procedures; Learns to prepare statistical reports;

Learns to code diseases, operations, and treatments according to the established nomenclature of diagnostic conditions;

Learns to respond to inquires regarding information in patient records;

Learns to maintain the confidentiality of health record in accordance with prescribed procedure;

Learns to maintain procedural manuals;

Learns to perform analyses of resident discharge records;

Learns to enter information into medical records and forms;

May use a digital voice recorder to transcribe medical records information;

Performs other related duties.

Knowledge of standard English and grammar;

Ability to learn the procedures and techniques for maintaining health records;

Ability to learn medical and general clinical terminology;

Ability to learn relevant federal, State and local regulations governing health records;

Ability to learn about diseases and their effects and treatments;

Ability to learn which standard treatments and tests are administered for specific diseases;

Ability to type accurately at a minimum of twenty net words per minute;

Ability to learn to code and index medical information according to recognized procedures;

Ability to learn to perform basic mathematics;

Ability to work effectively with members of the facility's staff and to advise them of medical records matters;

Ability to communicate effectively with co-workers, supervisors and the general public.

Education:   Graduation from an accredited high school or possession of a high school equivalency certificate.

Experience: None.

Note: Candidates may substitute experience compiling and maintaining health records on a year-for-year basis for the required education.

Class specifications are broad descriptions covering groups of positions used by various State departments and agencies. Position descriptions maintained by the using department or agency specifically address the essential functions of each position.

This is a Skilled Service classification in the State Personnel Management System.  All positions in this classification are Skilled Service positions.  Some positions in Skilled Service classifications may be designated Special Appointment in accordance with the State Personnel and Pensions Article, Section 6-405, Annotated Code of Maryland.

This classification is assigned to Bargaining Unit D- Health and Human Service Non-Professional classes.  As provided by State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, supervisory, managerial and confidential employees are excluded from collective bargaining.  Additionally, certain executive branch agencies are exempt from collective bargaining and all positions in those agencies are excluded from collective bargaining.

Employees in this classification are eligible to receive overtime compensation.  An employee who works more than the normal workweek is entitled to be compensated for that overtime as provided by State Personnel and Pensions Article, Section 8-305.

This classification is one level in a Non-Competitive Promotion (NCP) series.  NCP promotions are promotions by which employees may advance in grade and class level from trainee to full performance levels in a classification series.  In order to be non-competitively promoted to the next level in a NCP series an employee must: 1)  perform the main purpose of the class as defined in the Nature of Work section of the class specification; 2)  receive the type of supervision defined in the class specification, and 3) meet the minimum qualifications of the classification.